Sunday, 1 April 2012

What to do when you've done your hamstring

by Andrew Leipus in Cricinfo
Overwhelming feedback so far shows there are a lot of ESPNcricinfo readers out there currently suffering cricket injuries and they want some help. There are volumes of research out there but over the next few articles I will broadly discuss some guidelines on what I commonly see in practice, and provide some information that might be useful. Of course, it goes without saying that all injuries are unique and wherever possible you need to seek professional advice.

I have just read that my old captain of many years, Sourav Ganguly, has pulled a hamstring which kept him out of the Syed Mushtaq Ali Trophy quarter-final recently. Whilst this was unfortunate for Bengal, what was of interest was his comment that he will be fine by the time the IPL starts. This leaves him around two weeks in which to recover and complete his rehab. But the IPL also presents an interesting challenge to players, in that often they are coming off long seasons or a Test series. The increased intensity and speed of play during a Twenty20 is potentially a risk for the players, and where time allows, they should be gradually increasing their training intensity during the pre-camp. 

Sudden transition from standing around during Test cricket to explosive T20 is an injury waiting to happen and players need time to prepare adequately. I hope Sourav can recover in time. Unfortunately, hamstring strain injuries are a challenge for both the players and support staff, given their high incidence rate, slow healing, and a tendency to recur.

There is a continuum of muscle impairment that can occur in sport, ranging from simple muscle cramping or soreness to the worst-case scenario, of a complete rupture. We like to classify the degree of injury as a grade 1, 2, or 3, as it gives us an idea of how quickly we can get the player back to sport again. The greater the damage, the longer the rehabilitation period for restoration of full function.

Hamstring strains are quite common in cricket and can occur when overloaded eccentrically, like if the hamstring attempts to control a rapidly flexing hip/trunk or an extending leg, or both. This can happen during bowling, running between wickets or sprinting in the outfield, so every player is a potential victim. When the load applied or expected to be controlled by the muscle exceeds its capabilities, especially when on stretch, the muscle fibres tear or get damaged.

In terms of self-diagnosis, if you experience hamstring muscle soreness after a long day in the field or following training in the gym, the problem is unlikely to involve disruption of muscle fibres and will probably heal in a day or two. Many players experience this feeling after long days in the slips during a Test match. But a massage or ice bath in the evening will always help them recover by morning.
Actual muscle strains, however, always are accompanied by an acute onset of pain. A sudden, sharp "grabbing" behind the thigh is generally an indicator of a strain. Feeling pain or a swelling under your thigh when sitting is also quite indicative. The more intense the pain, generally, the higher the grade of injury.

The delineation between strong cramping and a mild strain is often difficult to diagnose, especially when the player is fatigued and dehydrated. This poses problems now that substitute runners are not allowed. Regardless, a grade 1 will probably let you continue playing, albeit with some discomfort, a grade 2 or 3 will bring you off the ground, limping. If this acute "grabbing" or "tearing" sensation isn't experienced and the hamstring pain arrives insidiously, there is a good chance the pain is being referred from surrounding areas like the lower back or pelvis. The management for this sort of injury is very different. There are many other possible sources of hamstring pain, often co-existing. This often results in a player return to sport remarkably quickly, since no muscle is actually injured at the time.

The initial management of all strains begins with protecting or offloading the muscle - applying an ice compression for 15-20 minutes every hour or two for a couple of days (commonly longer). A lot of people start to exercise too early post-injury, and in my experience sometimes it's better left alone, to allow for the natural healing processes to begin. A good rule of thumb to follow is not to do anything that hurts - it is common sense but not always followed, and leads to a premature return to sport, getting injured again, and even more time out of the game.

After a few days, when walking is easier, aim to gradually restore full range of movement, develop good alignment of scar tissue and regain optimal strength, since injured muscle becomes inhibited or weak almost immediately. Active stretching is useful in regaining movement - when sitting, use the quads to straighten the knee and provide a gentle hamstring stretch. It's much more preferable to static stretching at this stage. Soft-tissue massage is also beneficial to normalise muscle tone and soften the healing scar tissue.

A lot of people start to exercise too early post-injury, and in my experience sometimes it's better left alone, to allow for the natural healing processes to begin. A good rule of thumb to follow is not to do anything that hurts

A good sports physio will address these issues and examine for any other contributing or driving factors that may be modifiable, such as muscle imbalances, weakness, poor flexibility or dysfunctional movement patterns. In other words, they will look for reasons, biomechanical or otherwise, why the injury possibly occurred and try to correct or improve them.

After this, a progressive amount of training load is needed to strengthen the injured and weakened muscle without injuring it again. Some of the better traditional exercises prescribed early in rehabilitation don't require any equipment and include hip bridging off of a bench, squats, lunges, deadlifts and single-leg standing windmills.

Hamstring curl machines found in gyms certainly have their place in rehab but are a luxury not a necessity. Stationary cycling is also beneficial for maintaining cardio fitness and initially provides a low load to the hamstring. Access to a spin bike is useful if it has a weighted fly-wheel, since this will introduce an eccentric load to the hamstring. Eccentric loading has been shown to be a critical component to full hamstring rehabilitation.

Jogging can be reintroduced gradually, initially as sideways movements, which places less stress on the hamstrings. As pain-free contraction and full range of motion are regained, drills such as 80-metre run-throughs are common, like 20m of gradual acceleration leading into 40m of steady pace, followed by a deceleration over the next 20m. The distances and intensities of the acceleration and steady pace are gradually increased from session to session as the injured muscle adapts to increasing loads. Progression is based on the ability to complete each session successfully and wake up the next day without pain or stiffness. The ultimate goal is rapid acceleration into a full sprint, and for cricket, rapid changes of direction.

At some stage during this programme, cricketing skills will be reintroduced. For example, once lunging is comfortable it is quite reasonable to begin easy net sessions. Similarly, bowlers coming off hamstring strains need to begin "walking through" their actions, progressing to controlled medicine-ball throws and gradually bowling off a short run.

As mentioned at the start, there is no recipe. What you need instead is a structured and flexible progression of loading the injured muscle and the reintroduction of the necessary skills to avoid the development of altered movement patterns associated with the injury. The loads can be increased as the muscle becomes stronger, as can the progression of the gym programme to include more dynamic functional training and plyometrics/power training.

In terms of returning to play, don't be one of the many people who equate a lack of pain or stiffness with being fit. Prevention of re-injury starts with thorough rehabilitation of the current injury. Incorporating a dynamic warm-up before playing is the norm nowadays and static stretching is uncommon (although there still is a place for it). Bowling actions need to be reviewed carefully by the coach to ensure there is no altered movement - bowlers often don't finish their actions completely when recovering from a hamstring strain, and avoid short or full deliveries as they require a slightly longer delivery stride.

Ultimately, the best functional testing is seen under match conditions. Muscles tend to tighten when weak or fatigued and the best practice for this is to play a match, often at a lower grade than usual, in order to better control the efforts.

As you can see, there is a lot to cover in management of the "simple" hamstring strain and this has just been an introduction. But the best piece of advice I can give for prevention of hamstring strains is to be physically well conditioned. The more functionally strong the muscle, the less likely it is to fail.

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